Addiction Medicine
Canadian Society of Addiction Medicine
Last updated: October 2022
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High rates of relapse to opioids after withdrawal management is well established and results in an increased risk of overdose death, blood-borne illness infections, and non-fatal overdoses associated with significant long-term morbidity. Therefore, withdrawal management as a stand-alone treatment should be avoided, and patients must be carefully counselled regarding the significant risks of pursuing this course. Opioid agonist therapy is the gold standard for the management of opioid use disorder.
Sources:
British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder. Published June 5, 2017.
Canadian Research Initiative in Substance Misuse. CRISM National Guideline for the Clinical Management of Opioid Use Disorder. Published 2018.
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There is insufficient evidence regarding the utility of urine drug screening and its effect on health outcomes at the individual and community level. Furthermore, results must be interpreted with caution as they have limitations in sensitivity and specificity. Nevertheless, urine drug screens may be considered when confirming substance use at baseline, helping to assess clinical stability before and during the prescription of take-home doses, ensuring medications are being taken, when screening for illicit substances during treatment to evaluate safety and treatment response, and/or if it is in alignment with patient treatment goals.
Sources:
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
Kolla B, Callizo G, Schneekloth T. Utility of Urine Drug Testing in Outpatient Addiction Evaluations. J Addict Med. 2019 May 1;13(3):188-92. PMID: 30418336.
McEachern J. et al. Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. Int J Drug Policy. 2019 Feb; 64:30-33. PMID: 30551003.
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While confirmatory urine drug tests such as gas or liquid chromatography/mass spectrometry offer higher sensitivity and specificity and can provide qualitative and quantitative information, they are much more costly and can take days to weeks for results. This delay in results impacts the utility of confirmatory urine drug tests. Point-of-care immunoassays, in contrast, can provide real-time data to inform treatment and support shared decision-making.
Sources:
Beck O, Carlsson S, Tusic M, Olsson R, Franzen L, Hulten P. Laboratory and clinical evaluation of on-site urine drug testing. Scand J Clin Lab Invest. 2014 Nov; 74(8):681–6. PMID: 25046332.
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
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Witnessed or supervised urine drug screens remain a core component of many addiction treatment programs. There is insufficient evidence linking witnessing urine samples to improved patient-centred clinical outcomes.
Sources:
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
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There is limited evidence to support the use of benzodiazepines to manage opioid withdrawal symptoms during the induction of opioid agonist therapy. Moreover, concurrent opioid and benzodiazepine use is associated with an increased risk of respiratory depression, hypotension, and cardiac arrest. Benzodiazepines should not be routinely used for the treatment of opioid withdrawal.
Sources:
British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder. Published June 5, 2017.
Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015 June;9(5):358–367. PMID: 26406300.
Sun E, Dixit A, Humphreys K, Darnall B, Baker L, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: a retrospective analysis. BMJ. 2017 Mar; 356:j760. PMID: 28292769.
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Naltrexone is an evidence-based intervention for substance use disorders, including alcohol use disorder. Naltrexone is contraindicated in acute hepatitis and liver failure. In patients without suspected liver disease, pre-initiation liver function screening should not delay naltrexone treatment initiation. Based on available research, there is minimal risk of hepatoxicity associated with naltrexone prescribed at standard dose to treat alcohol use disorder (50mg). Additionally, the delay in treatment may result in patients being lost to care and not receiving an intervention that has the potential to support recovery. Periodic monitoring of liver enzymes is recommended for the alcohol use disorder population as part of comprehensive care.
Sources:
Anton, R. et al. Combined Pharmacotherapies and Behavioural Interventions for Alcohol Dependence. The COMBINE Study: A Randomized Controlled Trial. JAMA. May 2006;295(17), 2003-2017. PMID: 16670409.
Bolton M. et al. Serious adverse events reported in placebo randomized controlled trials of oral naltrexone systematic review and meta-analysis. BMC Medicine. 2019 Jan;17(10). PMID: 30642329.
Croop R. The Safety Profile of Naltrexone in the Treatment of Alcoholism. Arch Gen Psychiatry. 1997 Dec;54(12):1130-1135. PMID: 9400350.
Yen M, Ko H, Tang F, Lu R, Hong J. Study of hepatotoxicity naltrexone in the treatment of alcoholism. Alcohol. 2006 Feb;38(2):117-120. PMID: 16839858.
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Rates of buprenorphine detection in overdose deaths in Canada are rare, highlighting the relative safety of this medication for the treatment of opioid use disorder. Given the reassuring safety profile of buprenorphine and the low propensity for harm associated with diversion, more recent guidelines support flexibility in moving towards unwitnessed take-home doses for most buprenorphine prescriptions.
Sources:
Centre for Addiction and Mental Health. Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder. Published May 2021.
Crabtree A, Lostchuck E, Chong M, Shapiro A, Slaunwhite A. Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada. CMAJ. 2020 Aug;192(34):E967-72.
Lofwall MR, Walsh SL. A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world. Journal Addict Med. 2014;8(5):315-26. PMID: 25221984.
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Given the lack of evidence supporting improved outcomes with the discontinuation of buprenorphine in the context of acute pain and the high mortality risk associated with untreated opioid use disorder, buprenorphine should not be routinely discontinued in the context of acute pain or surgery.
Sources:
Anderson T, et al. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017 Jun;126(6):1180-1186. PMID: 28511196.
Goel A, et al. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for the perioperative management of buprenorphine: results of a modified Delphi process. British Journal of Anaesthesia. 2019 Aug; 123 (2): 333-342. PMID: 31153631.
Macintyre P, et al. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. 2013 Mar;41(2):222-230. PMID: 23530789.
Martin Y, et al. Perioperative opioid requirements of patients receiving sublingual buprenorphine-naloxone: a case series. BMC Anesthesiol. 2019 May;19(1):68. PMID: 31068127.
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The Canadian Society of Addiction Medicine- La société médicale Canadienne sur l’addiction (CSAM-SMCA) policy committee developed the Choosing Wisely Canada Addiction Medicine Recommendations above with input from addiction medicine providers working in diverse clinical settings across Canada.
The policy committee suggested an initial list of recommendations based on members’ clinical experience to limit addiction medicine interventions which could lead to patient harm, lack sufficient evidence and result in excess healthcare resource utilization. This list was shared with the CSAM-SMCA Board of Directors and the greater addiction medicine community through the META: PHI ListServ for review and additions.
A literature review for twelve initial recommendations followed to inform the evidence base and recommendation strength. These twelve recommendations were presented at the 2020 Family Medicine Forum, where conference attendees were encouraged to comment on, ask questions about, and vote on recommendations using a survey tool.
A Choosing Wisely Canada subcommittee of the CSAM-SMCA policy committee members was established in 2021 to further review and refine the recommendations to a final list of nine. The list of nine recommendations was sent out to the greater CSAM-SMCA membership in 2021 for input and review. Feedback and additional literature provided by CSAM-SMCA members were reviewed and integrated where applicable with input from the greater CSAM-SMCA Policy Committee. One recommendation was removed after review by the Choosing Wisely program as it did not fit the spirit of the Choosing Wisely recommendations. Please find the final list of eight recommendations above.
Sources:
British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder. Published June 5, 2017.
Canadian Research Initiative in Substance Misuse. CRISM National Guideline for the Clinical Management of Opioid Use Disorder. Published 2018.
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
Kolla B, Callizo G, Schneekloth T. Utility of Urine Drug Testing in Outpatient Addiction Evaluations. J Addict Med. 2019 May 1;13(3):188-92. PMID: 30418336.
McEachern J. et al. Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. Int J Drug Policy. 2019 Feb; 64:30-33. PMID: 30551003.
Beck O, Carlsson S, Tusic M, Olsson R, Franzen L, Hulten P. Laboratory and clinical evaluation of on-site urine drug testing. Scand J Clin Lab Invest. 2014 Nov; 74(8):681–6. PMID: 25046332.
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
British Columbia Centre on Substance Use, BC Ministry of Health, and Ministry of Mental Health and Addictions. Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment— Breakout Resource. Published July 28, 2021.
British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder. Published June 5, 2017.
Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med. 2015 June;9(5):358–367. PMID: 26406300.
Sun E, Dixit A, Humphreys K, Darnall B, Baker L, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: a retrospective analysis. BMJ. 2017 Mar; 356:j760. PMID: 28292769.
Anton, R. et al. Combined Pharmacotherapies and Behavioural Interventions for Alcohol Dependence. The COMBINE Study: A Randomized Controlled Trial. JAMA. May 2006;295(17), 2003-2017. PMID: 16670409.
Bolton M. et al. Serious adverse events reported in placebo randomized controlled trials of oral naltrexone systematic review and meta-analysis. BMC Medicine. 2019 Jan;17(10). PMID: 30642329.
Croop R. The Safety Profile of Naltrexone in the Treatment of Alcoholism. Arch Gen Psychiatry. 1997 Dec;54(12):1130-1135. PMID: 9400350.
Yen M, Ko H, Tang F, Lu R, Hong J. Study of hepatotoxicity naltrexone in the treatment of alcoholism. Alcohol. 2006 Feb;38(2):117-120. PMID: 16839858.
Centre for Addiction and Mental Health. Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder. Published May 2021.
Crabtree A, Lostchuck E, Chong M, Shapiro A, Slaunwhite A. Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada. CMAJ. 2020 Aug;192(34):E967-72.
Lofwall MR, Walsh SL. A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world. Journal Addict Med. 2014;8(5):315-26. PMID: 25221984.
Anderson T, et al. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017 Jun;126(6):1180-1186. PMID: 28511196.
Goel A, et al. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for the perioperative management of buprenorphine: results of a modified Delphi process. British Journal of Anaesthesia. 2019 Aug; 123 (2): 333-342. PMID: 31153631.
Macintyre P, et al. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. 2013 Mar;41(2):222-230. PMID: 23530789.
Martin Y, et al. Perioperative opioid requirements of patients receiving sublingual buprenorphine-naloxone: a case series. BMC Anesthesiol. 2019 May;19(1):68. PMID: 31068127.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Opioid Wisely
Encouraging thoughtful conversations about the harms associated with opioid prescribing.